In this interview, Dr. Atul Gawande projects a rather simplified and niave view of medicine.  What he failed to disclose are the differences between the Cheesecake Factory and hospitals.  For example, would the dining chain still serve a customer if he or she cannot pay?  Would the dinning chain still stay in business if it is required to have an “emergency feeding room” in an economically distressed section of the city without charity or government support.  Also, the number of diagnoses in medicine are significantly more than the number of dishes on the menu – compare the number of CPT codes with the number of dishes on the menu.  Medicine is far more complex than what was said in the interview.  Furthermore, having this discussion as an academic exercise that stimulates more research on this topic would be helpful.  But a public discourse without data that would lead to a change in public policy is disastrous and irresponsible.  Dr. Gawande is a surgeon, and surgeons tend to draw his/her experience on a case-by-case basis, as he cited his experience with his mother’s knee surgeries.  Remember, William Halstad was wrong in his thinking on the eradication of breast cancer.  It took a decade of clinical trials to prove that — but he was an excellent surgeon. 

It goes to prove my theorem: Over the last 30 years we moved from a public world to a private one in facets; Now, we are moving to a world of profitization, where only the profits matter.  When it is over, we will long for the halcyon days of the Robber Barons.

Wasn’t this what the change to HMO’s back in the 80′s was supposed to offer….more standards of care that are more consistent?  That certainly has not worked out to the promise.

I was recently admitted to the hospital after a bout of A. Fib., and the way my care was managed was a disaster.  My meds were messed up, even though the list was provided three times, to the ambulance crew, the ER nurse, and the admitting nurse.  I was not fed in the A.M., because I was supposed to have tests, but no one could say what they were.  When I saw my cardiologist, he said I could go home.  It took nearly 5 hours, and some pushing by me, before I was finally released.  Plus, that admittance will cost me $1500, versus $150 for an ER visit, which was all I needed.  

With the cookie cutter model, there is no room for independent thinking. You simply follow the “recipe”. The problem is that people are different and unique. Doctor’s need to assert their professional status and resist the cookie cutter.

The team approach among independent physicians and small groups, as it is done now, is by letters, if requested, I believe.  I think Blue Cross demands this, written reports from specialists to the primary doctor.  Presumably electronic transmissions and some standardization of what is transmitted will be helpful all around, and time-saving.  More paperwork?  Maybe.

the family care doctor has NOT been coordinating care…when my husband calls his father’s family care doctor to discuss his overall care, the doctor can not speak to the specifics of the oncology doctor or the cardiology doctor. He does indicate that there is a letter in the file, which he has to go read but there is not conversation between the specialists and the family care doctor. When my father-in-law is in the hospital, the family care doctor did not come to the hospital…a letter was sent to the file upon his release. In addition, many family care doctors do NOT stay current so the care they do give is less than optimal. I applaud this change!

I missed some of the beginning, but I’ve heard Gawande before on OnPoint and read a previous article.  The list approach, it seems to me, needs constant updating, by any office, because medicine is changing.  Say the doctor who mostly does the researching and coordinating for the office points out that XYZ, and the nurses and everyone shift to that.  It happens all the time.  Different specialties would shift at different rates, depending how current and aggressive the office guide-people are.

What concerns me is that  there is no CARE in health care – it is a fragmented , disjointed system, a chain restaurant  model is also scary – there are so many variables with our patients  - crabcakes don’t have feelings and opinions.   As a physician I try to treat my patients like a family member,  While I understand that we need to follow algorithms, get feedback, improve constantly… What ever happened to  TALKING to patient and  FAMILY seems to be forgotten in this whole process. Going back, checking in, communicating – every person has  a different view of issues particularly around the end of life.    There is no way charge or reimburse for the time that it takes to communicate effectively with patients and families and other healthcare providers, so it doesn’t get done.   

We don’t need Health Insurance, we need Health CARE!  The for profit model works great for restaurant chains, it is not appropriate for health care. 

I would like to see the health care system follow the construction industry model of a general contractor who is my contact point and he selects/recommends the tradesmen/specialists who have the best reputations and skills for my situation. This idea may work well for a hip replacement, but will breakdown when my care requires I leave my locale to access more advanced services.

Dr. Gawande identifies key problems in health care and suggests important elements of a solution, the modern, well-designed industrial process, but I believe misses key differences between health care and industrial processes: 1) It’s much more complex than producing meals (Cheesecake Factory or McDonalds), delivering packages (Fedex), or successfully completing a commercial airline flight, more like banking (very “rational” but – oops). Following a very good guideline, which should be followed 60-80% of the time, is bad medicine 20-40% of the time. 2) High-quality care is multiple, distinct concepts: less “bad” variability, fewer errors, quicker uptake of good practices, more patient-centered care and more cost effective care. The Cheesecake Factory model addresses only a couple of these, but is likely to emphasize efficiency and variability/errors (but see above about guidelines), and consumers can’t evaluate health care but can evaluate meals and vote with their feet. 3) A successful process is collaborative; the process he describes in essentially top-down, not collaborative (yes, suggestions are entertained, but…). It’s an important contribution, but it just starts the process (and perhaps perpetuates inexact generalizations and incompletely thought-thru conventional wisdom). 

I have two major concerns:  hospitalists replacing family doctors in the inpatient hospital scene who are coordinating care for someone they only just met and the overall ICU focus on the medical condition rather than the human condition.  Lewis Thomas, author of “The Youngest Science” shared these words about the process of his first personal experience with a kind of illness requiring hospitalization and high-intensity therapies, “…it was like being launched personless on the assembly line of a great (but quiet) factory. I was indeed handled as an object needing close scrutiny and intricate fixing, procedure after procedure and test after test, carted from one part of the hospital to another day after day until the thing was settled.  While it was going on I felt less like a human in trouble and more like a scientific problem to be solved as quickly as possible.  What made it work, and kept such notions as “depersonalization” and “dehumanization” from even popping into my mind, was the absolute confidence I felt in the skill and intelligence of the people who had hold of me.  In part this came from my own knowledge, beforehand, of their skill, but in larger part my confidence resulted from observing, as they went about their work, their own total confidence in themselves.”  While Dr. Thomas appears to find good things and bad about the modern, well-designed hospital industrial process, how does this make you feel?

Our organization, the Schwartz Center for Compassionate Healthcare, did a national poll a few years ago of 800 recently hospitalized patients and 500 doctors. Despite the fact that both patients and doctors expressed a strong desire for better coordination and continuity of care, 60% of patients said their PCP had not been in touch with them while they were in the hospital, 30% said they never met the physician in charge of their care before they entered the hospital, and a quarter of all patients said they did not know who was in charge of their care while they were in the hospital. It’s no wonder that so many Americans are disillusioned and dispirited about our healthcare system.

Hospitals are not factories, and patients are not cheesecakes, and Steward Health Care is no model for health care delivery in America, they are everything that is wrong with health care in America.  They are owned by Cerberus, a private equity firm that in addition to running hospitals, is also one of the largest gun manufacturers in the world.  Nurses, who spend more time with patients than any other provider and who have watched these business models and factory models (this is nothing new or innovative) be forced on clinicians and patients for the last 20 years can tell you that this approach does not work.  From a nurses’ perspective, assembly line practices means they are assigned more patients than they can safely care for and those patients are moved through the system quicker and sicker regardless of the needs of the patients or the capacity for nurses to provide the care these patients need.  We don’t need doctors and nurses stationed in bunkers looking at video screens monitoring patients, we need real nurses and physicians on the ground in these units observing patients and talking to them and caring for them in a way that we know works and works well.  Cerberus/Steward and Partners and all these other providers are not moving to these “assembly line” restaurant chain models of care to provide better care, they are moving to these models to provide care at a cheaper price, and in the case of Steward, their mission is to do this for their private investors.  Nurses, who are ethically and morally bound to advocate for their patients will not remain silent and pretend that this approach is either acceptable or effective. 

so a chain restraunt is the answer to soaring health care costs in the US?NO model eliminating the profit motive will be considered?Hey are we CITIZENSS or mere consumers? Once againNPR aquieces to corporate America.

Off topic perhaps yet relevant.   As a self employed middle aged single female I pay almost $7,000 a year for health insurance that covers….nothing.  My “well” visit is covered and my other “well” check ups, eyes every two years etc.  But if I get SICK, or INJURED I have to satisfy my $2,000 deductible.  So we’re looking at $9,000 a year.   The last two years that this deductible came upon the scene, I have had to spend two hours on the phone each year fighting for my “well” yearly physical to be paid.  Because now with a deductible, suddenly the blood tests my physician has been ordering for the last 18 years as part of my “well” physical are “not medically necessary”.  And my “well” physical (where, by the way, you cannot have any complaints (e.g. don’t dare say you are tired!) or it becomes a “sick” visit, which goes to your deductible” that is supposed be free is now costing me $500.00.  This is in Massachusetts.  I am a healthy person and I cannot even imagine what very sick people have t go through. 

I miss the good ole days, which seem not so long ago, when a person was sick or injured, you went to the doctor and did not have to worry.  No longer and this is a travesty. 

I am glad that the Affordable Care Act will do away with the criminal act of insurance companies being able to deny care to human beings due to “pre–existing conditions” but as a self employed person I am not sure it will help with health insurance premiums and I anticipate if I remain self employed, it will cost me $15,000 a year to insure myself.  In the “land of the free”  Why is health insurance still tied to one’s EMPLOYMENT STATUS on in this country with an unemployment rate of 8%?  It doesn’t make any sense.